GM CASE

July 29th 2023

Case scenario..
Im Sanjana MP,3rd year bds student. This is an online elog book to discuss our patients health data after taking his consent. This also reflects my patients centered online learning portfolio.

Case history 
A 57 years old man, who is a farmer by occupation.

Chief complaint: 
Patient was presented with altered sensorium since yesterday. Patient was apparently alright 3days back then he stopped using injection MIXTARD since 3days. Patient had history of irrelevant talk since yesterday but able to recognise people. 

History of present illness: 
Patient has low grade fever since yesterday ,intermittent in nature, relieved on medication.  Not associated with cold ,cough,vomiting, loose stools etc.
No SOB, chest pain, palpitations,  edema or decreased urine output.


History of past illness: 
Patient came with similar complaints in February of 2022, then he was diagnosed with diabetic nephropathy.
Patient had history of fever with chills for 4days 
Diabetes mellitus - since 1½ year
TB - 2years ago used ATT for 6months
Chronic pancreatitis and chronic kidney disease
Hypertension- 1year 
No history of CAD, asthma, surgeries

Personal history:
Appetite- lost 
Diet- mixed
Bowel- regular
Micturition- normal
Allergies- no
Addictions - chronic alcoholic and chronic smoker since 30years

Family history: 
Not significant 

General examination:
Pallor- yes
Icterus- no
Cyanosis - no
Clubbing - no
Lymphadenopathy- no
Pedal edema- no

Vitals: 
Temperature- 99' C
Pulse rate - 84
Respiration rate - 21/min

Systematic examination :
Patient is conscious but incohorent.
Respiratory examination: dyspnoe- no
Wheeze- no
Position of trachae - central
Breath sounds- vesicular

Abdomen examination: shape of abdomen:scaphoid
Tenderness- not
Palpable mass- no
Hernial orifice- normal
Liver- not palpable 
Spleen - not palpable 
Bowel - no





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